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Adjuvant and Palliative Radiotherapy in ACC

Radiotherapy and Locoregional Oncology

Adjuvant and palliative radiotherapy in adrenocortical carcinoma (ACC) refers to external-beam radiation delivered either after surgery to reduce the risk of locoregional recurrence or in advanced disease to relieve symptoms and control selected threatening lesions. Within ACC care, radiotherapy is a locoregional modality that complements surgery for resectable disease and systemic therapy for metastatic or biologically aggressive disease, rather than replacing either approach.123

Its rationale reflects the natural history of ACC. After resection, some patients experience relapse in the adrenal bed or adjacent retroperitoneum, particularly when margins are positive, tumor rupture or spillage has occurred, or there is locally invasive disease.456 At the same time, distant metastasis remains common and often determines prognosis, which limits the extent to which better local control can be expected to improve overall survival.789

The evidence base is limited and consists predominantly of retrospective institutional series, registry studies, propensity-matched analyses, and meta-analyses of observational data.10711 Across these sources, the most reproducible signal is that postoperative radiotherapy may reduce local or locoregional recurrence in selected high-risk patients, whereas survival benefits remain uncertain and may reflect selection bias, heterogeneity in stage and margin status, and incomplete adjustment for mitotane use, radiation technique, and other cointerventions.45126

In advanced ACC, radiotherapy is used mainly for palliation or focal control of symptomatic or anatomically dangerous lesions, including bone, brain, spinal, and unresectable local recurrences.131415 Modern conformal techniques, including IMRT, image guidance, stereotactic body radiotherapy, and radiosurgery, have expanded technical feasibility, but uncommon applications remain supported mostly by small series and case reports with limited generalizability.161718

Diagnostic and therapeutic context

Radiotherapy occupies a selective place in ACC management because complete surgical resection remains the main curative-intent treatment for localized disease, while systemic therapy is central when disease is metastatic, recurrent, or rapidly progressive.23 Postoperative irradiation is intended to sterilize residual microscopic disease in the tumor bed and adjacent high-risk tissues, especially after adverse operative or pathologic findings.119

This distinction is relatively consistent across the literature: radiotherapy is best supported as a local-control intervention. Its effect on recurrence-free survival and overall survival is less reliable, because distant failure is frequent and comparative evidence remains nonrandomized.79 Clinically, this means radiotherapy decisions are usually individualized within multidisciplinary care and weighed alongside stage, margin status, capsular or adjacent-organ invasion, and planned mitotane therapy rather than viewed as a standalone treatment choice.38

Adjuvant postoperative radiotherapy

Patients most commonly considered

Adjuvant radiotherapy is most often reported after resection of ACC with features associated with high locoregional relapse risk, including positive or close margins, tumor rupture or spillage, capsular or surrounding-organ invasion, stage III disease, and bulky primaries.1196 These indications are based primarily on recurrence patterns and retrospective practice rather than prospective comparative trials.

The overall direction of risk stratification is fairly reliable: patients with unfavorable local features appear most likely to derive local-control benefit. By contrast, the role of adjuvant radiotherapy after margin-negative resection or in lower-stage disease remains less certain, and thresholds for treatment vary across centers.208

Local control and survival

Most observational studies and pooled analyses suggest that adjuvant radiotherapy is associated with lower local recurrence after surgery.45107 This finding has been reported in both older and more contemporary series and is biologically plausible given the recognized pattern of adrenal-bed and retroperitoneal relapse in some high-risk patients.166

The effect on survival is more heterogeneous. Some institutional and population-based analyses report improved overall survival, particularly in positive-margin, stage III, or otherwise high-risk subgroups, whereas other registry and matched studies do not show a clear overall benefit.212211232412 The most practical interpretation is that postoperative radiotherapy may be justified to reduce locoregional failure in selected patients, but routine claims of survival advantage should remain cautious because residual confounding is likely.2526

Technique and target considerations

Postoperative treatment generally focuses on the adrenal bed and adjacent high-risk regions, with planning informed by operative findings and by the proximity of bowel, kidney, liver, and spinal cord.199 Contemporary conformal planning likely improves feasibility and toxicity relative to older techniques, especially in the retroperitoneum.169

What appears reasonably reliable is that modern techniques permit postoperative doses commonly used in ACC series with acceptable tolerability. What remains uncertain is the optimal dose, the role of elective nodal irradiation, and whether specific planning strategies improve oncologic outcomes beyond reducing treatment-related toxicity.69

Palliative and focal radiotherapy in advanced disease

As disease becomes unresectable or metastatic, the purpose of radiotherapy shifts from postoperative risk reduction to symptom relief and lesion-specific control. Common indications include painful bone metastases, spinal or epidural disease, neurologic compromise, brain metastases, vascular compression, and selected unresectable primary or recurrent lesions.11415

Retrospective data suggest that palliative radiotherapy may relieve pain and produce local control in a substantial proportion of treated lesions, particularly at symptomatic bone and other metastatic sites.131417 Higher biologically effective dose approaches, including SBRT in selected patients, may provide more durable lesion control than lower-dose conventional schedules, although this inference comes from nonrandomized data and strong patient selection is likely.17

The practical implication is that radiotherapy is a useful palliative tool and may be considered for focal control of oligoprogressive or high-risk lesions, but it does not substitute for systemic therapy in patients with widespread disease. Benefit depends heavily on lesion site, symptom burden, pace of progression, and expected survival.227

Less common metastatic sites and unusual applications

For intracranial metastases, pooled retrospective experience suggests that surgery with or without radiotherapy offers the best chance of meaningful local control when feasible, although overall prognosis remains poor.15 For rare situations such as unresectable functioning primaries or mobile cardiac metastases, stereotactic approaches mainly demonstrate technical feasibility in highly selected patients rather than establishing standard practice.282918

These reports are useful for illustrating possibilities but are not reliable for estimating comparative effectiveness or safety. In practice, uncommon ACC irradiation scenarios require individualized planning, and isolated success stories should not be generalized without caution.2918

Toxicity, limitations, and special considerations

Reported toxicity from ACC radiotherapy is usually mild to moderate, with gastrointestinal symptoms, fatigue, nausea, and transient treatment-related effects most often described.1678 Severe late toxicity appears uncommon in published series, but the true incidence is uncertain because most data are retrospective, follow-up may be limited, and rare complications can be underreported.79

The most reliable practical conclusion is that modern radiotherapy is generally feasible and often well tolerated when carefully planned. Less reliable are estimates of rare late effects, especially after reirradiation or treatment near critical structures; isolated reports of radiation-related myelopathy reinforce the importance of organ-at-risk constraints.30

Additional caution may be warranted in hereditary cancer predisposition syndromes. Correspondence and expert opinion have emphasized that germline TP53-associated syndromes may alter the risk-benefit balance of adjuvant radiotherapy, supporting genetic counseling and individualized decision-making rather than uniform postoperative use.3132 Pediatric ACC is an even less certain setting, because evidence is sparse and entirely retrospective.33

Indirect evidence from veterinary adrenal SBRT also illustrates a broader principle: technical feasibility does not by itself establish safety, and toxicity estimates from small series may be unstable.34 Although not directly applicable to human ACC, this supports caution when extrapolating from limited experience in uncommon adrenal irradiation scenarios.34

Role in management and research

Overall, radiotherapy in ACC is best understood as a selective locoregional adjunct. After resection, it is most relevant for patients at high risk of local failure; in advanced disease, it is used primarily for palliation or focal control of symptomatic or threatening lesions.1223

Current evidence most strongly supports improved local control, while effects on recurrence-free and overall survival remain uncertain.107 Recent multicenter and population-based studies suggest that benefit may be concentrated in enriched subgroups, such as patients with positive margins, stage III disease, or multiple adverse features, but these findings remain difficult to separate from treatment selection and other biases.353624

Research priorities therefore center on better patient selection, clearer integration with mitotane and systemic therapy, and more standardized postoperative target-volume and dose approaches. Until higher-quality comparative data are available, radiotherapy use in ACC remains individualized and guided mainly by local recurrence risk, symptom burden, technical feasibility, and multidisciplinary judgment.39

Included Articles

  • PMID 1709336: This small retrospective series describes postoperative radiation to the tumor bed and regional nodal areas for stage III adrenocortical carcinoma, suggesting improved local control and longer survival in selected patients after surgery. It also reports that palliative radiation provided symptomatic benefit for metastatic or unresectable disease.37
  • PMID 12891501: This pediatric case report describes percutaneous ethanol injection therapy for two small liver metastases detected 11 months after resection of a functional adrenocortical carcinoma. The lesions regressed with calcification and eventual disappearance on CT, with only mild transient liver function abnormalities reported.38
  • PMID 16895957: In a retrospective matched analysis of 14 irradiated and 14 nonirradiated patients after macroscopically complete ACC resection without distant metastases, adjuvant tumor-bed radiotherapy was associated with markedly lower local recurrence but no clear improvement in disease-free or overall survival. Toxicity was mostly mild, supporting postoperative radiotherapy as a locoregional control strategy requiring further prospective evaluation.4
  • PMID 17498906: A small case series suggests percutaneous laser ablation may provide palliative local control for unresectable primary or metastatic ACC, especially liver metastases, with improvement in performance status and reduction in cortisol excess in patients with Cushing syndrome. Major complications were not observed, but survival impact remained uncertain.39
  • PMID 18035298: A pediatric and young adult case report describes palliative celiac plexus blockade for metastatic adrenocortical carcinoma causing severe abdominal pain, with temporary relief after local anesthetic and steroid injection and later neurolytic alcohol block. Three-dimensional rotational angiography was used to confirm injectate spread during the procedure.40
  • PMID 19402169: This review summarizes retrospective evidence suggesting that radiotherapy has a role in ACC for both postoperative local control and palliation. It recommends considering adjuvant tumor-bed irradiation for patients at high risk of local recurrence, especially after R1 or incomplete resection, and using palliative radiotherapy for symptomatic bone, brain, or vena cava metastatic involvement.1
  • PMID 20220294: A retrospective Dutch registry analysis suggests ACC may not be uniformly radioresistant: palliative radiotherapy relieved pain in all treated bone metastases, and two evaluable patients with unresectable recurrent or metastatic disease achieved RECIST partial responses lasting more than 12 months. Limited adjuvant cases also showed no local recurrence in this small cohort.13
  • PMID 20675074: A retrospective single-center series found that radiotherapy was associated with improved local control in ACC, with lower local failure after surgery plus adjuvant radiotherapy than after surgery alone and durable control in selected unresectable cases treated definitively. Acute toxicity was common but usually limited to nausea or emesis, with few reported late effects.16
  • PMID 22488095: This review summarizes contemporary radiation therapy use in ACC, reporting improved local control with adjuvant postoperative radiation and suggesting a role for definitive radiation in unresectable disease, while confirming established palliative benefit for symptomatic metastases or bulky tumors.2
  • PMID 23150683: A retrospective matched cohort of 48 resected stage II-III ACC patients found that adjuvant radiotherapy after surgery did not significantly improve local recurrence-free survival, distant recurrence, recurrence-free survival, or overall survival versus surgery alone. The study also noted generally mild to moderate radiotherapy toxicity and emphasized the need for prospective multicenter trials.20
  • PMID 23867507: This retrospective series supports radiotherapy as a useful multimodality option in ACC, particularly for palliation of pain, neuropathy, and impending local metastatic complications, with most evaluable palliative treatments producing clinical improvement and low severe toxicity. Adjuvant radiotherapy was also used after positive margins or tumor spillage, but local-control conclusions were limited by very small numbers.14
  • PMID 25754631: In a matched retrospective cohort of 40 patients with localized ACC after gross resection, postoperative adjuvant radiation therapy to a median dose of 55 Gy was associated with markedly improved local control compared with surgery alone, but without significant recurrence-free or overall survival benefit. Toxicity was mostly low grade, and the authors note the need for prospective confirmation.5
  • PMID 26166227: This case report describes adjuvant helical IMRT with daily IGRT by tomotherapy after resection of bulky ACC with an R1 margin, delivering 63 Gy to the high-risk bed and 50.4 Gy to regional lymphatic drainage with acceptable toxicity. The report also summarizes retrospective evidence and guideline-style recommendations supporting consideration of adjuvant radiotherapy for positive or uncertain margins, stage III disease, or other high-risk features.19
  • PMID 26383682: This correspondence argues that adjuvant radiotherapy in localized ACC should be interpreted cautiously because hereditary cancer syndromes and TP53 alterations may influence radiosensitivity, second malignancy risk, and treatment benefit. It emphasizes routine genetic counseling and suggests mutation-informed patient selection for radiotherapy.31
  • PMID 26383683: This correspondence emphasizes that adjuvant radiotherapy decisions in localized ACC should account for germline TP53 mutation status and hereditary cancer syndromes. The authors state that genetic counseling is routinely warranted for all ACC patients and that they do not recommend adjuvant radiotherapy for patients with TP53 mutations.32
  • PMID 27477410: This case report describes stereotactic radiosurgery with CyberKnife for unresectable stage IV ACC with a giant primary adrenal mass, paraaortic nodal disease, and pulmonary artery tumor emboli. Short-term follow-up showed reduced FDG uptake, decreased cortisol and DHEA-S levels, symptom improvement, and no reported treatment complications.28
  • PMID 27566097: A small retrospective series of three patients with ACC-related metastatic spinal cord compression found that palliative radiotherapy provided partial pain relief but did not improve motor function or ambulatory status; median survival after treatment was only two weeks. The authors suggest supportive care alone may be reasonable when pain can be controlled without irradiation.27
  • PMID 27655879: This case report describes radiation-induced myelomalacia causing progressive paraparesis after postoperative tumor-bed radiotherapy for cortisol-secreting adrenocortical carcinoma. It emphasizes that this rare toxicity is a diagnosis of exclusion, requiring imaging and other evaluation to rule out metastatic disease, and notes possible increased susceptibility with hypercortisolemia.30
  • PMID 28445297: A population-based SEER propensity score analysis of 530 adults with ACC found no overall or cancer-specific survival benefit from radiotherapy, including after stage-stratified analyses. The article notes radiotherapy may still help with local control or palliation, while emphasizing important evidence limitations such as missing dose, modality, margin, and mitotane data.12
  • PMID 28727379: A retrospective matched cohort and meta-analysis suggest adjuvant radiotherapy after ACC resection may lower or delay local recurrence, with no demonstrated improvement in recurrence-free or overall survival. Toxicity was generally acceptable, but the evidence base is limited to small retrospective series with substantial heterogeneity.10
  • PMID 28880439: A case report describes stage IV ACC with persistent liver-dominant metastatic disease after surgery and EDP-mitotane, followed by hepatic trans-catheter arterial chemoembolization that was associated with complete metabolic response and durable disease-free follow-up. The report also notes that evidence for liver-directed therapy in ACC is limited and supports multidisciplinary, research-oriented use.41
  • PMID 29748889: In a National Cancer Database analysis of 1184 patients with non-metastatic ACC after resection, adjuvant radiation was used infrequently and was not associated with improved overall survival in the full cohort. A subgroup with positive surgical margins showed a lower adjusted risk of death with adjuvant radiation, whereas other high-risk features did not show a survival benefit.21
  • PMID 30324475: A population-based NCDB analysis of 1184 patients with nonmetastatic ACC found that adjuvant radiation after surgery was infrequently used and did not improve median overall survival overall, but was associated with lower adjusted mortality in the positive-margin subgroup. The commentary emphasizes retrospective evidence for improved local control and the need for prospective study.22
  • PMID 30900615: A systematic review and meta-analysis of observational studies found that adjuvant radiotherapy after ACC resection was associated with lower local recurrence, while no significant benefit was shown for overall mortality or any recurrence. Reported toxicities were mostly mild and self-limited, with rare late renal impairment.7
  • PMID 31216954: A case report describes malignant inferior vena cava obstruction in metastatic ACC causing edema and ascites, with palliative endovascular stenting providing partial symptom relief and restored caval patency. The review notes that evidence for this locoregional approach is limited mainly to case reports and small series, and overall survival remains constrained by underlying disease.42
  • PMID 31220287: A retrospective propensity-matched single-institution study found that adjuvant postoperative radiotherapy to the tumor bed and adjacent lymph nodes after gross resection of localized or oligometastatic ACC was associated with improved locoregional recurrence-free survival, overall recurrence-free survival, and overall survival.3
  • PMID 31997752: A case report describes CT-guided crossed-probe cryoablation for a painful sclerotic L4 vertebral metastasis from adrenocortical carcinoma abutting the spinal canal after radiotherapy and chemotherapy were ineffective and surgery was declined. Treatment reduced FDG avidity and improved pain, but repeat ablation caused transient neurologic toxicity with eventual recovery.43
  • PMID 32448148: This retrospective study and updated meta-analysis evaluated postoperative adjuvant radiotherapy after curative-intent ACC resection. Although the institutional matched cohort did not show significant benefit, pooled retrospective data favored adjuvant radiotherapy for overall survival, locoregional recurrence-free survival, and disease-free survival, with evidence limited by nonrandomized study designs.25
  • PMID 34476529: A population-based SEER analysis of 294 adults with resected non-metastatic ACC found postoperative radiotherapy was associated with improved overall and cancer-specific survival, including after multivariable adjustment and propensity matching. The study also highlights major evidence limitations, including retrospective design and lack of radiotherapy dose and technique details.11
  • PMID 35601796: This review of pediatric ACC found radiotherapy evidence to be limited and entirely retrospective, precluding general recommendations, but suggests adjuvant radiotherapy may be considered individually for patients with positive margins or other high-risk features, with most treatments directed to the tumor bed during primary therapy.33
  • PMID 36482186: A multicenter retrospective study in advanced ACC found that radiotherapy achieved local lesion control in many treated sites, with better time to progression after higher-dose conventional radiotherapy or SBRT than after lower-dose conventional schedules. Toxicity was generally mild, while autonomous glucocorticoid excess was associated with worse progression outcomes.17
  • PMID 36860827: This retrospective single-center ACC series found low local relapse after adjuvant radiotherapy and good tolerability, with no grade III/IV toxicities. Capsular invasion and positive surgical margins independently predicted worse overall and relapse-free survival, supporting radiotherapy consideration mainly for local-control risk reduction rather than proven survival benefit.8
  • PMID 37354248: A pooled analysis of 27 ACC patients with brain or leptomeningeal metastases found these events were rare and carried poor prognosis in adults, with median progression-free and overall survival of 2 and 7 months. Surgery with or without radiotherapy was the main local treatment and was identified as the only approach offering a chance for durable intracranial control.15
  • PMID 38260140: This retrospective single-center study of resected localized ACC found that postoperative adjuvant radiotherapy was associated with improved 3-year overall survival and longer disease-free survival versus surgery alone, with the clearest apparent benefit in ENSAT I/II disease and mostly mild-to-moderate toxicity.26
  • PMID 38341326: This case report describes inoperable intracardiac metastasis from adrenocortical carcinoma treated with MRI-guided stereotactic radiotherapy at 30 Gy in 5 fractions, with good short-term tolerance and partial radiographic response by 6 months. It highlights MRI guidance as a potential locoregional option for mobile cardiac lesions when surgery is not feasible.29
  • PMID 39420904: This case report describes stereotactic ablative radiotherapy as an alternative local treatment for unresectable or surgery-declined aldosterone-secreting ACC, with sustained tumor shrinkage, pain improvement, and biochemical control of hyperaldosteronism over prolonged follow-up. It also notes that radiotherapy evidence in ACC remains limited and largely retrospective.18
  • PMID 39618172: A retrospective propensity-matched single-center study found that adjuvant radiotherapy after curative-intent ACC resection was associated with lower local recurrence and higher 3-year locoregional recurrence-free survival, without a significant recurrence-free or overall survival benefit. The report also describes contemporary postoperative dosing around 50-60 Gy and highlights use in higher-risk settings such as incomplete resection or invasive tumors.6
  • PMID 39854744: A SEER-based retrospective study of 426 patients reported that adjuvant radiotherapy was independently associated with improved overall and cancer-specific survival in ACC, including an all-stage cohort. The study also developed nomograms incorporating radiation, surgery type, T stage, age, and bone or liver metastases for survival prediction.36
  • PMID 39862362: A propensity score-matched retrospective analysis of resected ACC found postoperative adjuvant radiotherapy was associated with improved overall survival, with the strongest apparent benefit in ENSAT stage III disease. A two-center stage III analysis also suggested better overall survival and local control with mitotane plus radiotherapy versus mitotane alone.23
  • PMID 41065970: A SEER-based propensity-matched analysis of adults with ACC after radical adrenalectomy found adjuvant radiotherapy was associated with improved overall survival after matching and on multivariable analysis, with apparent benefit concentrated in patients with at least two high-risk features such as older age, advanced stage, nodal involvement, large tumor size, or poor differentiation.24
  • PMID 41127690: A case of metastatic ACC with extremely rare endobronchial metastasis causing left mainstem obstruction showed that rigid bronchoscopy with cryo-debulking and fully covered self-expanding bronchial stenting can restore airway patency and improve ventilation as a palliative locoregional intervention, though overall prognosis remained poor.44
  • PMID 41399138: In a retrospective multicenter cohort of 23 patients with high-risk localized ACC treated after complete resection with adjuvant mitotane plus modern postoperative radiotherapy, locoregional control was high and severe radiotherapy toxicity was not observed. Distant metastasis remained the predominant pattern of failure, and the authors emphasize the exploratory, noncomparative nature of the evidence.9
  • PMID 41537654: A case of metastatic ACC with an L2 vertebral body fracture, epidural extension, and neural compression was managed with preoperative arterial embolization followed by minimally invasive spinal corpectomy and fixation, enabling subsequent adjuvant radiation therapy with symptom resolution and no reported perioperative complications at 14 months.45
  • PMID 33858789: A 2021 population-based study examined stage presentation, care patterns, and outcomes in ACC, including the association between radiotherapy and overall survival. It complements prior retrospective series by adding real-world survival data while underscoring persistent selection bias and heterogeneity in treatment use.35
  • PMID 41410158: A 2026 multi-institutional veterinary retrospective series of SBRT for canine adrenal tumours, including a few suspected adrenocortical carcinomas, reported radiographic responses but unexpectedly high severe gastrointestinal toxicity and treatment-related mortality. Its relevance to human ACC is indirect, but it adds caution regarding assumptions of safety for adrenal SBRT based on small feasibility reports.34

References

Footnotes

  1. Radiotherapy in adrenocortical carcinoma.. Cancer. 2009. PMID: 19402169. Local full text: 19402169.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  2. The role of radiation therapy in the management of adrenal carcinoma and adrenal metastases.. J Surg Oncol. 2012. PMID: 22488095. Local full text: 22488095.md ↩ ↩2 ↩3 ↩4 ↩5

  3. Adjuvant Radiation Improves Recurrence-Free Survival and Overall Survival in Adrenocortical Carcinoma.. J Clin Endocrinol Metab. 2019. PMID: 31220287. Local full text: 31220287.md ↩ ↩2 ↩3 ↩4 ↩5

  4. Efficacy of adjuvant radiotherapy of the tumor bed on local recurrence of adrenocortical carcinoma.. J Clin Endocrinol Metab. 2006. PMID: 16895957. Local full text: 16895957.md ↩ ↩2 ↩3 ↩4

  5. Adjuvant radiation therapy improves local control after surgical resection in patients with localized adrenocortical carcinoma.. Int J Radiat Oncol Biol Phys. 2015. PMID: 25754631. Local full text: 25754631.md ↩ ↩2 ↩3 ↩4

  6. Adjuvant Radiotherapy After Surgical Resection Improves Local Control in Adrenocortical Carcinoma.. Asia Pac J Clin Oncol. 2025. PMID: 39618172. Local full text: 39618172.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  7. Adjuvant radiotherapy after surgical resection for adrenocortical carcinoma: A systematic review of observational studies and meta-analysis.. J Cancer Res Ther. 2019. PMID: 30900615. Local full text: 30900615.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8

  8. Treatment outcomes of adjuvant radiotherapy in adrenocortical carcinoma - A 13-years experience from a tertiary care centre.. Rare Tumors. 2023. PMID: 36860827. Local full text: 36860827.md ↩ ↩2 ↩3 ↩4 ↩5

  9. Impact of Adjuvant Radiotherapy and Mitotane on Survival in Localized Adrenocortical Carcinoma: A Retrospective Cohort Study.. Int J Urol. 2026. PMID: 41399138. Local full text: 41399138.md ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8

  10. Adjuvant radiotherapy for the primary treatment of adrenocortical carcinoma: Are we offering the best?. Int Braz J Urol. 2017. PMID: 28727379. Local full text: 28727379.md ↩ ↩2 ↩3 ↩4

  11. Impact of postoperative radiotherapy on the outcomes of resected adrenocortical carcinoma-a real-world, population-based study.. Strahlenther Onkol. 2022. PMID: 34476529. Local full text: 34476529.md ↩ ↩2 ↩3

  12. The efficacy of radiation therapy in adrenocortical carcinoma: A propensity score analysis of a population-based study.. Medicine (Baltimore). 2017. PMID: 28445297. Local full text: 28445297.md ↩ ↩2 ↩3

  13. Response to radiation therapy in adrenocortical carcinoma.. J Endocrinol Invest. 2010. PMID: 20220294. Local full text: 20220294.md ↩ ↩2 ↩3

  14. Role of radiotherapy in adrenocortical carcinoma.. Cancer J. 2013. PMID: 23867507. Local full text: 23867507.md ↩ ↩2 ↩3 ↩4

  15. Outcome of brain metastases from adrenocortical carcinoma: a pooled analysis.. J Endocrinol Invest. 2024. PMID: 37354248. Local full text: 37354248.md ↩ ↩2 ↩3 ↩4

  16. Adjuvant and definitive radiotherapy for adrenocortical carcinoma.. Int J Radiat Oncol Biol Phys. 2011. PMID: 20675074. Local full text: 20675074.md ↩ ↩2 ↩3 ↩4 ↩5

  17. Efficacy and safety of radiation therapy in advanced adrenocortical carcinoma.. Br J Cancer. 2023. PMID: 36482186. Local full text: 36482186.md ↩ ↩2 ↩3 ↩4

  18. Stereotactic radiotherapy as a valuable therapeutic procedure for controlling aldosterone-secreting adrenocortical carcinoma.. Arch Endocrinol Metab. 2024. PMID: 39420904. Local full text: 39420904.md ↩ ↩2 ↩3 ↩4

  19. Adjuvant helical IMRT by tomotherapy for bulky adrenocortical carcinoma operated with positive margins: a case report.. Tumori. 2016. PMID: 26166227. Local full text: 26166227.md ↩ ↩2 ↩3 ↩4

  20. A retrospective cohort analysis of the efficacy of adjuvant radiotherapy after primary surgical resection in patients with adrenocortical carcinoma.. J Clin Endocrinol Metab. 2013. PMID: 23150683. Local full text: 23150683.md ↩ ↩2

  21. Adjuvant Radiation is Associated with Improved Survival for Select Patients with Non-metastatic Adrenocortical Carcinoma.. Ann Surg Oncol. 2018. PMID: 29748889. Local full text: 29748889.md ↩ ↩2

  22. ASO Author Reflections: Incorporating Adjuvant Radiation into the Treatment Planning for Select Adrenocortical Carcinomas.. Ann Surg Oncol. 2018. PMID: 30324475. Local full text: 30324475.md ↩ ↩2

  23. Adjuvant radiation therapy improves outcome of patients with surgical resected adrenocortical carcinoma.. Endocrine. 2025. PMID: 39862362. Local full text: 39862362.md ↩ ↩2 ↩3

  24. The choice of adjuvant radiotherapy in adrenocortical carcinoma patients after radical adrenalectomy: a population-based analysis.. Discov Oncol. 2025. PMID: 41065970. Local full text: 41065970.md ↩ ↩2 ↩3

  25. Efficacy of adjuvant radiotherapy for treatment of adrenocortical carcinoma: a retrospective study and an updated meta-analysis.. Radiat Oncol. 2020. PMID: 32448148. Local full text: 32448148.md ↩ ↩2

  26. Efficacy and safety of adjuvant radiation therapy in localized adrenocortical carcinoma.. Front Endocrinol (Lausanne). 2023. PMID: 38260140. Local full text: 38260140.md ↩ ↩2

  27. Prognosis of Patients with Metastatic Spinal Cord Compression from Adrenocortical Carcinoma.. In Vivo. 2016. PMID: 27566097. Local full text: 27566097.md ↩ ↩2

  28. Adrenocortical Carcinoma Treated by CyberKnife.. Intern Med. 2016. PMID: 27477410. Local full text: 27477410.md ↩ ↩2

  29. Stereotactic magnetic resonance imaging-guided radiotherapy for intracardiac metastases: A case report.. Cancer Radiother. 2024. PMID: 38341326. Local full text: 38341326.md ↩ ↩2 ↩3

  30. Unusual cause of paraparesis in a patient with Cushing’s syndrome.. BMJ Case Rep. 2016. PMID: 27655879. Local full text: 27655879.md ↩ ↩2

  31. Adjuvant Radiation Therapy and Local Control After Surgical Resection in Patients With Localized Adrenocortical Carcinoma: In Regard to Sabolch et al.. Int J Radiat Oncol Biol Phys. 2015. PMID: 26383682. Local full text: 26383682.md ↩ ↩2

  32. In Reply to Purushothaman et al.. Int J Radiat Oncol Biol Phys. 2015. PMID: 26383683. Local full text: 26383683.md ↩ ↩2

  33. Radiotherapy for pediatric adrenocortical carcinoma - Review of the literature.. Clin Transl Radiat Oncol. 2022. PMID: 35601796. Local full text: 35601796.md ↩ ↩2

  34. Outcome and Toxicity Profile of Stereotactic Body Radiation Therapy for Adrenal Tumours in Dogs.. Vet Comp Oncol. 2026. PMID: 41410158. Local full text: 41410158.md ↩ ↩2 ↩3

  35. Stage Presentation, Care Patterns, Treatment Outcomes, and Impact of Radiotherapy on Overall Survival for Adrenocortical Carcinoma.. Clin Genitourin Cancer. 2021. PMID: 33858789. Local full text: 33858789.md ↩ ↩2

  36. Adjuvant radiation improves survival outcomes in adrenocortical carcinoma: A population-based study.. Medicine (Baltimore). 2025. PMID: 39854744. Local full text: 39854744.md ↩ ↩2

  37. Radiation therapy for adjunctive treatment of adrenal cortical carcinoma.. Am J Clin Oncol. 1991. PMID: 1709336. Local full text: 1709336.md ↩

  38. A child with adrenocortical carcinoma who underwent percutaneous ethanol injection therapy for liver metastasis.. J Pediatr Surg. 2003. PMID: 12891501. Local full text: 12891501.md ↩

  39. Percutaneous laser ablation of unresectable primary and metastatic adrenocortical carcinoma.. Eur J Radiol. 2008. PMID: 17498906. Local full text: 17498906.md ↩

  40. Celiac plexus blockade in children using a three-dimensional fluoroscopic reconstruction technique: case reports.. Reg Anesth Pain Med. 2007. PMID: 18035298. Local full text: 18035298.md ↩

  41. Complete response in a patient with stage IV adrenocortical carcinoma treated with adjuvant trans-catheter arterial chemo-embolization (TACE).. Asia Pac J Clin Oncol. 2018. PMID: 28880439. Local full text: 28880439.md ↩

  42. Endovascular Treatment of Inferior Vena Cava Thrombosis in Metastatic Malignancy: A Case Report and Review of Literature.. Vasc Endovascular Surg. 2019. PMID: 31216954. Local full text: 31216954.md ↩

  43. Crossed-Probes Cryoablation for the Treatment of a Sclerotic Vertebral Metastasis Abutting the Spinal Canal.. J Vasc Interv Radiol. 2020. PMID: 31997752. Local full text: 31997752.md ↩

  44. Role of Palliative Bronchial Stenting in Endobronchial Metastasis: An Atypical Case of Metastatic Adrenocortical Carcinoma in a Young Patient.. Clin Case Rep. 2025. PMID: 41127690. Local full text: 41127690.md ↩

  45. Minimally Invasive Tubular Transpedicular Partial Corpectomy and Percutaneous Segmental Posterior Fixation With a Combined Titanium and Carbon Fiber Construct: 2-Dimensional Operative Video.. Oper Neurosurg. 2026. PMID: 41537654. Local full text: 41537654.md ↩

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